Diphtheria in asylum workers: forgotten but not gone!
Authors: Parul C. Gupta, Prakasini Satapathy, Ankur Gupta, Mubarick N. Asumah, Bijaya K Padhi
Journal: International Journal of Surgery (2023)

Dear Editor, Human mobility and relocation are critical to the spread of infectious diseases. Diphtheria is understood as an 'illness of the prevaccination times' due to increased vaccine uptake globally. Therefore, many clinicians in most countries, including the United Kingdom, have hardly seen cases of diphtheria. However, infrequent cases and rarely epidemic outbreaks have been described, specifically in politically unbalanced regions where there are pockets of unvaccinated people, such as diphtheria outbreaks in Rohingya refugee campsites1. In the past, diphtheria outbreaks have also been registered in other conflict areas such as Yemen, Venezuela, and Germany2–4. Recently, there has been a rise in cases of diphtheria at immigrant shelters around Europe. More than 70 cases have been reported in England and detained at the Manston airport detection center in Kent in the past few days5. More than 40,000 asylum seekers have traversed the English Channel on boats this year. Manston, which was previously a military base, is intended to house barely 1600 individuals. However, in October, there were around 4000 migrants held there. Of these, one migrant worker died of diphtheria on November 19, after entering the United Kingdom 7 days earlier. He tested positive for the polymerase chain reaction testing6 Children in the United Kingdom are routinely immunized against infection, reducing the danger to the general population. Due to this high rate of diphtheria vaccination in the United Kingdom and the fact that the illness is principally propagated through close and extended contact with a patient, the risk of transmission of diphtheria to the general community is proposed to be relatively less5. However, many asylum applicants are denied this protection, as the majority of them have not been previously immunized, probably due to limited access to healthcare in their native countries. The European Center for Disease Control and Prevention has advised these places to take precautions, including immunizing asylum seekers before moving them elsewhere, to prevent overcrowding and poor ventilation. The government has advised migrants to take vaccines and antibiotics upon arrival6. Another school of thought suggests that the asylum seekers were in the incubation period and already infected before they arrived in England. This may be the result of prolonged lockdowns imposed during the coronavirus disease-2019 pandemic that substantially, hampered the implementation of vaccine schedules substantially as seen in the latest measles outbreak in India. Diphtheria is a major health problem in nations with low coverage of vaccination. It is a vaccine-preventable bacterial disease, although it is highly contagious and possibly lethal. In children under 5 years of age and adults over 40 years, the mortality rate may be as high as 20%. It can be asymptomatic or cause fever, headache, sore throat, 'bark cough', painful swallowing, difficulty breathing, blood-stained nasal discharge, skin ulcers, and lymphadenopathy. A thick, grayish 'pseudomembrane' is formed in the conjunctiva, nasal, and throat mucosa. Ocular involvement includes blepharoconjunctivitis and corneal ulcers7. Cardiac arrhythmias, heart blocks, myocarditis, and heart failure can occur due to the toxin's effects in severe cases. Nerve palsy and kidney failure are also documented in some patients. This disease is spread by coughing, sneezing, or contact with utensils, bedding, or injuries from an infected patient. After being diagnosed by direct microscopy, culture, or multiplex polymerase chain reaction, the cornerstone of treatment includes antibiotics and antitoxins8,9. The way forward The WHO endorses global vaccination for Td (tetanus and diphtheria) for unvaccinated people 7 years of age and older. Unvaccinated contacts must receive a full course of diphtheria toxoid-containing vaccine, and incompletely vaccinated contacts should receive the remaining doses needed to complete their vaccination schedule. Erythromycin tablets can be distributed to all contacts of diphtheria patients10. Improved standards of housing, mass immunization, definitive diagnosis, timely treatment, and more efficient health support have also led to a decrease in the caseload of diphtheria worldwide, although not entirely. The government, along with local authorities, public health professionals, and microbiologists, should support affected persons and thwart the spread of infection in the broader interests of the public through constant epidemiological surveillance. Efficacy and adherence to the immunization program should be monitored periodically, along with the provision of booster doses. The availability of ample doses of diphtheria antitoxin for the rapid management of patients in such outbreaks must be ensured. Contact tracking and chemoprophylaxis of all contacts are the way forward. Robust protocols and contingency strategies to contain the outbreak must be part of the targeted action plan. Undoubtedly, the most effective approach would be to guarantee universal coverage of diphtheria through extended immunization programs. Health policy makers and physicians should not underestimate the value of primary and booster vaccinations against diphtheria among travelers to contain the spread of this disease. Ethical approval and informed consent Ethical approval and informed consent were not required for this study. Sources of funding There was no source of funding for this research. Authors contribution Equally contributed. Conflicts of interest disclosure The authors declare no conflict of interest. Guarantor Mubarick Nungbaso Asumah and Bijaya K. Padh. Data availability Data sharing is not applicable to this article as no new data were created.